Corrective Action Plans

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This finding is due to the District not having the proper controls in place to prevent, detect, or correct an incorrect monthly meal claim. The month that had the incorrect meal claim used incomplete Z-Reports which resulted in the meal claim being submitted for less than it should have been. The pe...
This finding is due to the District not having the proper controls in place to prevent, detect, or correct an incorrect monthly meal claim. The month that had the incorrect meal claim used incomplete Z-Reports which resulted in the meal claim being submitted for less than it should have been. The persons responsible for the corrective action are Lisa Newton, the Food Service Director and Corey Bordo, the Director of Business and Finance. The anticipated completion date of the corrective action plan is immediate. The plan for monitoring adherence is the Food Service Director will ensure that all meal counts are final on the Z-Report before the claim requests are made.
Housing Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: We recommend that the Authority implements controls to ensure HUD-50058 recertifications are uploaded to PIC. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken i...
Housing Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: We recommend that the Authority implements controls to ensure HUD-50058 recertifications are uploaded to PIC. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The 3 exceptions have been uploaded. PHA’s Information Systems Management (ISM) Department has implemented a secondary quality control measure to confirm that all 50058 files have been successfully uploaded; the Vice President of Application Support will conduct routine and regular reviews of 50058 file uploads to ensure that transactions have been submitted and uploaded timely. Name(s) of the contact person(s) responsible for corrective action: Cynthia Hallman, Vice President – Application Support Planned completion date for corrective action plan: Upload is complete, quality control check has been implemented and ongoing.
2025-004 Eligibility Contact Person – Lora Papacheck, CEO Planned Corrective Action – Management agrees with the recommendation and will review their policies and procedures to ensure all applications are maintained and the file checklist is completed. Completion Date – Fiscal year 2026
2025-004 Eligibility Contact Person – Lora Papacheck, CEO Planned Corrective Action – Management agrees with the recommendation and will review their policies and procedures to ensure all applications are maintained and the file checklist is completed. Completion Date – Fiscal year 2026
2025-003 Allowable Costs/Cost Principles Contact Person – Lora Papacheck, CEO Planned Corrective Action – Management agrees with the recommendation and will review their policies and procedures to ensure out-of-state travel is approved in advance and documentation is kept supporting the approval. Co...
2025-003 Allowable Costs/Cost Principles Contact Person – Lora Papacheck, CEO Planned Corrective Action – Management agrees with the recommendation and will review their policies and procedures to ensure out-of-state travel is approved in advance and documentation is kept supporting the approval. Completion Date – Fiscal year 2026
Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the USDA program reserve fund. Corrective Action Plan: Manage...
Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the USDA program reserve fund. Corrective Action Plan: Management will ensure a review separate from the preparer of the reconciliation for the program's reserve fund is completed with formal documentation noting the review. The Business Office Manager will reconcile the bank statement and will sign off on the bank statement, along with the Administrator for the USDA Loan Reserve Bank Account. Responsible Individuals: Gerry Leadbetter, Administrator Anticipated Completion Date: January 2026
The first step was to hire a director of finance (the 3rd hirer in the past 2 years passed away suddenly) which was completed in February 2025. The second step was to hire third party CPA consultants familiar with accounting system to correct activity and design of system for ongoing use. Finally, t...
The first step was to hire a director of finance (the 3rd hirer in the past 2 years passed away suddenly) which was completed in February 2025. The second step was to hire third party CPA consultants familiar with accounting system to correct activity and design of system for ongoing use. Finally, training of support staff and monitoring of the monthly accounting procedures completed upon correction of historical activity.
Replacement Reserve Monthly Deposits Not Made Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Project should made the required deposits monthly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in res...
Replacement Reserve Monthly Deposits Not Made Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Project should made the required deposits monthly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will make the required deposits monthly as cash flow allows. Name(s) of the contact person(s) responsible for corrective action: Mary Gilberts, Management Agent Planned completion date for corrective action plan: June 2026
Finding Number: 2025-001 Condition: The Organization deposited prior year surplus cash 56 days after the deadline stated in the Real Estate Assessment Center’s Summary of Financial Reporting and Auditing Guidance for HUD (FRAG Guide) under Section 2.8. Planned Corrective Action: Management has ackno...
Finding Number: 2025-001 Condition: The Organization deposited prior year surplus cash 56 days after the deadline stated in the Real Estate Assessment Center’s Summary of Financial Reporting and Auditing Guidance for HUD (FRAG Guide) under Section 2.8. Planned Corrective Action: Management has acknowledged noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Management deposited the surplus cash amount of $39,601 into residual receipts on November 25, 2024. Contact person responsible for corrective action: Tyler Luce Anticipated Completion Date: November 25, 2024
Finding Number: 2025-001 Condition: Withdrawals totaling $13,846 were made from the replacement reserve without HUD authorization. Planned Corrective Action: Management has acknowledged noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Mana...
Finding Number: 2025-001 Condition: Withdrawals totaling $13,846 were made from the replacement reserve without HUD authorization. Planned Corrective Action: Management has acknowledged noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Management has deposited the underfunded amount of $13,846 to the replacement reserve account on July 10, 2025. Contact person responsible for corrective action: Tyler Luce Anticipated Completion Date: July 10, 2025
Finding Number: 2025-001 Condition: The Organization accrued for and expensed an invoice for professional service fees incurred by another project. Planned Corrective Action: Management has acknowledged noncompliance in the current fiscal year and has taken measures to improve internal controls to e...
Finding Number: 2025-001 Condition: The Organization accrued for and expensed an invoice for professional service fees incurred by another project. Planned Corrective Action: Management has acknowledged noncompliance in the current fiscal year and has taken measures to improve internal controls to ensure the invoice approval process is adequate for professional fees to ensure expenses are charged to the project that incurred the cost. Contact person responsible for corrective action: Tyler Luce Anticipated Completion Date: June 30, 2025
Finding Number: 2025-002 Condition: During testing of tenant files, it was noted that the EIV report was missing for one tenant. Planned Corrective Action: Management has acknowledged the noncompliance and related internal control deficiency over compliance and will implement proper procedures and c...
Finding Number: 2025-002 Condition: During testing of tenant files, it was noted that the EIV report was missing for one tenant. Planned Corrective Action: Management has acknowledged the noncompliance and related internal control deficiency over compliance and will implement proper procedures and controls to ensure EIV is properly utilized. Contact person responsible for corrective action: Tyler Luce Anticipated Completion Date: June 30, 2026
Finding Number: 2025-001 Condition: The Organization paid for expenses and an invoice for professional service fees incurred by another project. Planned Corrective Action: Management has acknowledged noncompliance in the current fiscal year and has taken measures to improve internal controls over co...
Finding Number: 2025-001 Condition: The Organization paid for expenses and an invoice for professional service fees incurred by another project. Planned Corrective Action: Management has acknowledged noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Management received reimbursement from the other project on September 8, 2025. Contact person responsible for corrective action: Tyler Luce Anticipated Completion Date: September 8, 2025
Finding Number: 2025-001 Condition: The Organization deposited prior year surplus cash seven days after the deadline stated in the Real Estate Assessment Center’s Summary of Financial Reporting and Auditing Guidance for HUD (FRAG Guide) under Section 2.8. Planned Corrective Action: Management has ac...
Finding Number: 2025-001 Condition: The Organization deposited prior year surplus cash seven days after the deadline stated in the Real Estate Assessment Center’s Summary of Financial Reporting and Auditing Guidance for HUD (FRAG Guide) under Section 2.8. Planned Corrective Action: Management has acknowledged noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Management deposited the surplus cash amount of $8,731 into residual receipts on October 7, 2024. Contact person responsible for corrective action: Tyler Luce Anticipated Completion Date: October 7, 2024
Finding Number: 2025-001 Condition: Withdrawals totaling $8,603 were made from the replacement reserve without HUD authorization. Planned Corrective Action: Management has acknowledged noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Manag...
Finding Number: 2025-001 Condition: Withdrawals totaling $8,603 were made from the replacement reserve without HUD authorization. Planned Corrective Action: Management has acknowledged noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Management has deposited the underfunded amount of $8,603 to the replacement reserve account on September 3, 2025. Contact person responsible for corrective action: Tyler Luce Anticipated Completion Date: September 3, 2025
Auditee’s Response and Planned Corrective Action: Management concurs with the audit finding and recognizes the need for enhanced controls over tenant selection and admissions. 4 | P a g e Planned Corrective Action: The Authority will update, formally adopt, and implement its Admissions and Continued...
Auditee’s Response and Planned Corrective Action: Management concurs with the audit finding and recognizes the need for enhanced controls over tenant selection and admissions. 4 | P a g e Planned Corrective Action: The Authority will update, formally adopt, and implement its Admissions and Continued Occupancy Policy (ACOP) and Administrative Plan to clearly define HUD-compliant waiting list management, preferences, tenant selection, and admissions procedures. Staff training will be conducted, and management will perform ongoing compliance reviews. Sustainability Measures: Admissions and waiting list controls will be sustained through formal policy adoption, recurring staff training, documented compliance reviews, and periodic policy updates to ensure ongoing alignment with HUD Public Housing and HCV program requirements.
Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing #10.766 Compliance Requirement: Special Tests and Provisions Finding Summary: The Center's reserve account is fully funded per the requirements of the loan resoluti...
Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing #10.766 Compliance Requirement: Special Tests and Provisions Finding Summary: The Center's reserve account is fully funded per the requirements of the loan resolution security agreement. However, there is no documented secondary monitoring of the reserve balance as compared to the required minimum reserve balance. Responsible Individuals: Crystal Richter, Interim CFO Corrective Action Plan: Hired an Accountant July 2025. Management will ensure there are multiple people involved and overseeing the reserve balance and documentation will be retained review and approval over the reserve balance. Anticipated Completion Date: December 2025
2025-001 Costs Incurred Beyond the Period of Performance Criteria: According to 2 CFR §§200.1, 200.308, 200.309, 200.344, and 200.403(h), a non-Federal entity may only charge allowable costs incurred during the approved budget period of the Federal award’s period of performance, and any costs incurr...
2025-001 Costs Incurred Beyond the Period of Performance Criteria: According to 2 CFR §§200.1, 200.308, 200.309, 200.344, and 200.403(h), a non-Federal entity may only charge allowable costs incurred during the approved budget period of the Federal award’s period of performance, and any costs incurred before the Federal award was made that were authorized by the Federal awarding agency or pass-through entity. All financial obligations incurred under the Federal award must be liquidated within the required time period. Costs incurred outside the approved period of performance are unallowable and constitute questioned costs. Client’s Response: During the grant cycle, the Organization submitted for an extension but did not receive confirmation of said extension. During the current fiscal year, the Organization has implemented additional controls to ensure that all grant funding is expended within the timeframe allotted. Proposed Implementation Date – 12/31/2025 Name of Contact Person – John Edwards, Sr. Email: jledwards@umadaop.org Phone: 419-255-4444
Condition: Controls in place did not minimize the time elapsing between the transfer receipt of billing from the subrecipient and disbursement of federal dollars to the subrecipient in accordance with the guidance above. Planned Corrective Action: Federation typically receives vouchers from 15 subre...
Condition: Controls in place did not minimize the time elapsing between the transfer receipt of billing from the subrecipient and disbursement of federal dollars to the subrecipient in accordance with the guidance above. Planned Corrective Action: Federation typically receives vouchers from 15 subrecipient organizations approximately ten to fifteen days after the end of each month. The number of vouchers per agency depends on the number of programs they provide. Staff reviews the vouchers for allowability and accuracy and submits them to the Illinois Department of Human Services (IDHS) within 24 days of month end. During fiscal year 2025, the IDHS remitted payment to Federation anywhere from 20 to 82 days after the month end. Upon receipt of the cash, Federation typically pays subrecipient organizations within two to three business days. In the instances identified by the auditors, the IDHS remitted payment over 30 days after Federation submitted the vouchers for reimbursement. Federation’s longstanding policy has always been to reimburse each subrecipient agency after it has received payment from the IDHS. Prior to fiscal year 2024, the IDHS usually provided payment within 15 days of receipt of our voucher and therefore Federation was able to comply with the 30-day requirement. However, reimbursement delays from IDHS began to occur in fiscal year 2024 and continued throughout fiscal year 2025, resulting in the findings describe herein. IDHS made two advance payments to Federation during fiscal 2025, but the amounts provided were not adequate to fund all payments within the 30 day time period. To ensure compliance with the 30-day reimbursement requirement, Federation will again request advances from the IDHS. Kyu Kim, Director of Finance and Contract Compliance, Refugee Services will be responsible for the oversight of the reimbursement payments. Contact person responsible for corrective action: Kyu Kim Anticipated Completion Date: July 2026
RE: Finding Reference Number: 2025-001 Corrective Action: Sea Mar will implement a compliance worksheet that will be used by staff to ensure they have collected all necessary documentation for each tenant. This tool will assist in tracking income verification documents and move-in/move-out dates and...
RE: Finding Reference Number: 2025-001 Corrective Action: Sea Mar will implement a compliance worksheet that will be used by staff to ensure they have collected all necessary documentation for each tenant. This tool will assist in tracking income verification documents and move-in/move-out dates and will be included as a cover sheet for each tenant file. Sea Mar will also provide staff with additional training on eligibility determination for qualifying applicants in alignment with applicable program guidelines. This will be completed by 3/31/2026. Name of Contact Person Responsible for Implementation: John Clerkin, Housing Director Sincerely, John Clerkin Housing Director P: (206) 788-3399 E: johnclerkin@seamarchc.org Proudly serving the community since 1978
Management's Response: Management concurs with the finding and has taken corrective action by formalizing the procurement policy in a written document reviewed by the Board of Trustees at their meeting on August 26, 2025.
Management's Response: Management concurs with the finding and has taken corrective action by formalizing the procurement policy in a written document reviewed by the Board of Trustees at their meeting on August 26, 2025.
View of the Responsible Official: We agree with the significant deficiency identified. Responsible Persons: School-based food service coordinators and Management director of food service Management Response: Training is conducted annually with school-based food service coordinators to ensure proper ...
View of the Responsible Official: We agree with the significant deficiency identified. Responsible Persons: School-based food service coordinators and Management director of food service Management Response: Training is conducted annually with school-based food service coordinators to ensure proper understanding of reporting requirements. During the 2025-2026 year standardized forms have been distributed to all school food service locations to ensure accurate counting and calculations, which will align with the monthly claim reimbursement reports submitted for reimbursement. It is the expectation that all school-based food service coordinators will properly utilize the updated forms and will receive training as necessary to ensure a thorough understanding of the importance of accurate reporting. Management’s food service director will increase oversight of the meal counts and claims reports to verify the accuracy of the reporting, and to ensure that the count records agree to the claims submitted. Anticipated Completion Date: June 30, 2026
Corrective Action Plan Finding Reference: 2025-001 – Allowable Activities/Allowable Costs Federal Program: CFDA 84.010 – Title I Fiscal Year Ended: June 30, 2025 Corrective Action Plan Condition The audit identified weaknesses in internal controls over payroll charges to Title I, creating a risk tha...
Corrective Action Plan Finding Reference: 2025-001 – Allowable Activities/Allowable Costs Federal Program: CFDA 84.010 – Title I Fiscal Year Ended: June 30, 2025 Corrective Action Plan Condition The audit identified weaknesses in internal controls over payroll charges to Title I, creating a risk that costs may be charged to the program in error. Root Cause Although program coding is built into the payroll system during employee setup, controls were not consistently documented or monitored, particularly for staff working across multiple funding sources and for private school Title I employees. A lack of secondary review allowed for one miscoding error and inconsistent position information between contracts and timesheets. Corrective Actions to Be Taken 1. Payroll Coding Review: Implement a second-level review process, led by the Business Manager, to verify all federal program payroll coding each pay period before submission. 2. Position Alignment: Require a monthly reconciliation of contracted positions against timesheet records to ensure consistency. 3. Private School Documentation: Effective immediately, require written wage documentation from private schools for all Title I-funded employees, with documents retained for audit purposes. 4. Update the written procedures related to federal and state funded payroll charges and provide refresher training for payroll and program staff by December 31, 2025. Responsible Officials - Business Manager – Oversight and monitoring of corrective actions - HR/Payroll Specialist – Implementation of payroll coding and reconciliation procedures - Title I Coordinator – Verification and retention of private school documentation Completion Date All corrective actions will be fully implemented by December 31, 2025. Monitoring and Sustainability The District will conduct quarterly internal reviews of Title I payroll activity, maintaining a monitoring log, requiring time and effort sheets and retaining documentation in the business office. Annual refresher training will be provided to ensure ongoing compliance with federal requirements. Views of Responsible Officials The District concurs that stronger documentation and monitoring are necessary. Program coding is established in the payroll system during employee setup, and controls exist to ensure proper allocation. The purpose of the timeclock system is to log hours. The issue arose due to insufficient secondary review rather than the absence of program coding. Immediate corrective measures have already been taken, and the District is committed to implementing the above actions to ensure full compliance with 2 CFR 200.303 and 2 CFR 200.430(g).
Finding Number: 2025-002 Condition: The Corporation failed to refund the security deposit to a tenant within 30 days of their move out date. Planned Corrective Action: Management acknowledges noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance...
Finding Number: 2025-002 Condition: The Corporation failed to refund the security deposit to a tenant within 30 days of their move out date. Planned Corrective Action: Management acknowledges noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Management returned the security deposit to the former tenant on February 21, 2025. Contact person responsible for corrective action: Julie Fratianne, CFO Anticipated Completion Date: 2/21/2025
Finding 2025.002 - Sliding Fee Scale Discount Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Action Taken • Monthly Audits o The Front Office Coordinators at each location will routinely audit...
Finding 2025.002 - Sliding Fee Scale Discount Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Action Taken • Monthly Audits o The Front Office Coordinators at each location will routinely audit sliding fee verification on a monthly basis to verify that information has been captured and recorded correctly and all proof of income documentation is received. These monthly audits will be adopted as standard protocol and procedure for front office operations, effective January 2025. Any findings through the audit process will be reported to the COO. At least five patient charts will be audited monthly. o In addition, the Revenue Cycle Manager will also review audit findings or summaries to ensure adequate adjustment to patient accounts to correlate with the patient's eligibility status. • Staff Training o Although Heartland has offered periodic sliding fee scale procedure training, administration will be scheduling additional training with a focus on required documentation and proper analysis and implementation of sliding fee discounts. o COO and Revenue Cycle Manager will review, implement and update standard operating procedure for sliding fee scale verification. o Employees will receive a copy of the sliding fee scale policy and sign that they have read the material. o Front office employees at all locations will complete a sliding fee schedule competency check-off sheet that will be reviewed by the Front Office Coordinators and Revenue Cycle Manager.
Finding Number: 2025‐001 Program Name/Assistance Listing Title: Temporary Assistance for Needy Families (TANF) Assistance Listing Number: 93.558 Contact Person: Elise Lopez – Vice President, Organizational Operations Anticipated Completion Date: January 31, 2026 Planned Corrective Action: The TANF C...
Finding Number: 2025‐001 Program Name/Assistance Listing Title: Temporary Assistance for Needy Families (TANF) Assistance Listing Number: 93.558 Contact Person: Elise Lopez – Vice President, Organizational Operations Anticipated Completion Date: January 31, 2026 Planned Corrective Action: The TANF Cash Assistance eligibility for each client served is one of the dozens of data points that Emerge tracks as part of our requirements for the Arizona Department of Economic Security (ADES) funding. The categorization of whether clients are eligible for TANF Cash Assistance, while a reporting requirement, is not tied to our contract billing. In other words, the accuracy of this categorization does not affect Emerge’s funding in any manner, and reporting errors regarding this categorization has not – and cannot – result in over‐billing for service units within the contract. Nevertheless, Emerge takes its reporting obligations very seriously and strives to always provide the most complete and accurate data to funders and the community. In regard to determining a client’s eligibility for TANF Cash Assistance or other government benefits, Emerge collects information and assesses eligibility for two reasons: 1) as a means of supporting our case management services and efforts to connect clients with appropriate resources, and 2) in order to comply with ADES requests to report whether or not we serve TANF‐eligible clients. While Emerge and its employees are not trained by ADES in determining individual’s eligibility for TANF Cash Assistance or other government benefits that we do not administer, we do provide our own internal training to employees about the factors that go into determining eligibility. Historically, this information has been provided as a stand‐alone document and noted during new hire training. In researching the client files which were selected for audit, it was determined that, in some instances, clients were categorized incorrectly, or that qualifying information was not sufficiently documented as it pertains to the client’s TANF Cash Assistance eligibility. Overwhelmingly, this was a result of one or both of the following factors: (1) clients whose TANF eligibility changed during the year, but whose status was not updated in our system, and/or (2) inconsistencies in how a client’s children had been documented in our client information system (eg. clients whose children are not enrolled in Emerge’s services do not appear in this system, but staff may have marked the client eligible for TANF based on verbal information without documenting the children in their notes). Our internal inquiry into this issue also revealed that TANF income eligibility charts were not correctly updated in all areas of the client information system, which may have led to confusion among staff regarding client eligibility status changes throughout the year. To mitigate future errors, we have taken immediate steps to begin the process of updating our client information system to ensure the correct TANF eligibility charts are reflected in the appropriate areas. We also have a plan to update TANF eligibility chart updates annually, which will include a quality assurance check by the Vice President of Operations to ensure the information has been updated in all appropriate areas of the client data managements system. As of November 28, 2025, we have developed an internal performance improvement plan. This plan includes conducting an internal audit of our client information system files for 2025 to ensure accuracy, re‐training staff on TANF eligibility and documentation, and conducting monthly quality assurance checks through the end of FY26. Additionally, greater time and focus related to the details surrounding the TANF assessment process will be built into the curriculum for new hire trainings moving forward. These corrective actions, while ongoing, are expected to be fully implemented by 01.31.2026
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